If you are a nurse, a physical therapist or an occupational therapist applying to work in the United States, you have probably seen a number like this on the HRSA requirements page:
4.5 Speaking.
And if you are holding a TOEFL score report from before 2026, that number makes no sense. Your report says 24, or 26, or 22. Nothing on it says 4.5. So you are left wondering whether you already passed, whether you are close, or whether you need to book another test.
Here is what is actually happening, and what you need to do about it.
The 4.5 is on the new TOEFL scale, not the old one
On January 21, 2026, ETS moved TOEFL scoring from the old 0 to 30 per section scale to a banded scale of 1 to 6, reported in half-point steps. Every section now gets a band between 1 and 6, and those bands are aligned to CEFR levels.
HRSA updated its requirements to match. The problem is that the HRSA table prints the bare number and never says which scale it is using. So "4.5 Speaking" looks alarming if you are comparing it to a score report that runs to 30.
It is a band. Not a percentage, and not a score out of 30.
The requirements, before and after
HRSA's current English proficiency requirements took effect on May 12, 2026. Here is what changed, by profession.
| Profession | Old requirement (May 2022 to May 2026) | Current requirement (from May 12, 2026) |
|---|---|---|
| Occupational therapists and physical therapists | 89 overall, 26 Speaking | 4.5 overall, 4.5 Speaking, 3.5 Reading, Listening and Writing |
| Registered nurses and other B.S. level workers | 81 overall, 24 Speaking | 4.5 overall, 4.5 Speaking, 3.5 Reading, Listening and Writing |
| Below B.S. level workers | 77 overall, 24 Speaking | 4 overall, 4.5 Speaking, 3 Reading, Listening and Writing |
Now put the new numbers next to the official ETS concordance, which tells you what each band was worth on the old scale.
| New Speaking band | Old Speaking score | CEFR level |
|---|---|---|
| 6 | 28 to 30 | C2 |
| 5.5 | 27 | C1 |
| 5 | 25 to 26 | C1 |
| 4.5 | 23 to 24 | B2 |
| 4 | 20 to 22 | B2 |
| 3.5 | 18 to 19 | B1 |
| 3 | 16 to 17 | B1 |
So Speaking 4.5 is the same bar as the old 23 to 24.
If you are a physical or occupational therapist, the bar just dropped
This is the part almost nobody has noticed, and it matters if you have been preparing for months.
The old requirement for therapists was Speaking 26. On the new scale, 26 sits inside band 5. The new requirement is 4.5, which is the old 23 to 24.
That is a drop of one full band, and it changes what you need to do. If you have been grinding toward a 26 because that was the number on the old page, you are now aiming higher than your own licensure body asks for. A great deal of TOEFL preparation content still treats "Speaking 26" as the target for healthcare workers, because for years it was.
For registered nurses the picture is different. The old requirement was 24 and the new one is 4.5, which covers 23 to 24. In practice that is roughly the same bar. Nurses did not get a discount. Therapists did.
For below B.S. level workers, note something odd in the table: the overall requirement is 4, but the Speaking requirement is 4.5. Speaking is the only section where you are asked to score above your own overall requirement. If you are in this group, Speaking is the section that decides whether you pass.
TOEIC is no longer an option
One more change from the same date. TruMerit, which issues the VisaScreen certificate, has stated that it will no longer accept TOEIC for VisaScreen certification after the May 12 implementation date.
If TOEIC was your plan, it is not a plan any more. You need TOEFL, IELTS or OET instead. That is worth acting on early, because switching tests means switching preparation.
What band 4.5 actually requires from you
Band 4.5 is a reachable target. It is not an elite score. In the practice answers I score, it sits close to the middle of the range rather than at the top.
That is the good news. The bad news is that most people aim at it with the wrong instincts. So here is what my own data says about what moves a Speaking score, based on roughly 3,300 scored interview responses.
Speaking more is the single biggest lever. The number of words in a response correlates with the score at about 0.84, and it outweighs every other feature I measure. When someone asks me what to fix first, this is the answer almost every time. Short answers cap your score no matter how clean they are.
Silence costs you close to a full point. I split responses into ten groups by how much of the answer is silence. The least silent tenth averaged 4.45 on the 0 to 5 scale I score practice answers on. The most silent tenth averaged 3.54. That is a gap of 0.91. The number of separate silent gaps in a response correlates with score at about negative 0.57.
Speaking faster does not hurt you. This surprises people, and I got it wrong myself in an earlier post before I checked. Average scores rise steadily as speaking rate rises, all the way through the fastest group I measured. The reason is that speaking rate is really a measure of how much you said in the time available, so it tracks the same thing as volume. The only real ceiling is whether you stay understandable.
Advanced vocabulary does almost nothing on its own. Once I control for how much the person said, vocabulary sophistication has essentially no independent effect on the score. Reaching for an impressive word in a short answer does not rescue the short answer.
Filler sounds are a symptom, not the penalty. Controlling for silence and length, the rate of "um" and "uh" has no measurable independent effect. A filled pause beats a silent gap. But responses heavy in fillers still score worse overall, because heavy filler use travels with more silence, fewer words and a slower pace. Among responses light in fillers, about 22 percent reached the top band I track. Among the heaviest, about 8 percent did. Policing the sound tends to backfire into silence. The thing to fix is the planning problem underneath it.
| What test takers usually do | What the data supports |
|---|---|
| Slow down to sound careful | Keep talking. Slower and shorter scored lower, not higher. |
| Pause to find a better word | Use the ordinary word. The pause costs more than the word gains. |
| Memorise advanced vocabulary lists | Build answers you can extend. Length does the work. |
| Train yourself to never say "um" | Prepare material you can retrieve quickly, so you do not need to stall at all. |
The other licensure gates, so you are not reading the wrong page
Requirements differ sharply by profession, and people lose weeks to this.
Pharmacists. NABP's FPGEC certification requires Speaking band 5 for tests taken on or after January 21, 2026. Band 5 is the old 25 to 26, which is CEFR C1. That is a higher bar than nurses and therapists face.
Physicians. ECFMG does not accept TOEFL at all. Its certification pathways require the Occupational English Test for Medicine, across all four sub-tests, with no exceptions. If you are a doctor and someone sold you a TOEFL course for your licensure, you were sold the wrong product.
One more warning. NCSBN still has a document online recommending an overall 84 with a minimum Speaking of 26. That document is a research brief from August 2009, written for the old 0 to 120 scale, and it still circulates. Check the requirement with the body that will actually certify you, and check the date on whatever page you are reading.
What I would do this week
Find your exact requirement from your own certifying body and write down the band. Then find out where you currently stand on the same scale, because comparing an old score report to a new requirement is where most of the confusion starts. If your last test was before January 2026, use the concordance table above to translate it.
Then work on the gap in the order the data supports. Length first, silence second, and clarity as the constraint on both.
If you want to see where you actually sit against band 4.5 rather than guessing, you can record practice answers and get them scored with ETS Scoring technology at toefl.myspeakingscore.com. Seeing which measured behaviour is holding you back is considerably faster than taking the real test again to find out.
Frequently asked questions
Is TOEFL Speaking 4.5 a good score?
For HRSA purposes it is the passing bar for registered nurses, therapists and below B.S. level workers. On the ETS concordance, band 4.5 equals the old 23 to 24 and corresponds to CEFR B2.
My score report says 24. Do I meet the 4.5 requirement?
On the official ETS concordance, an old Speaking score of 23 or 24 maps to band 4.5. Confirm with the body processing your application how it treats score reports issued before January 21, 2026, since ETS is reporting both the band and a comparable older-style score through January 2028.
Did the requirement for physical and occupational therapists get easier?
Yes. The old requirement was Speaking 26, which falls in band 5. The current requirement is 4.5, which is the old 23 to 24. That is a drop of one full band.
Is TOEIC still accepted for VisaScreen?
No. TruMerit has stated it will no longer accept TOEIC for VisaScreen certification after the May 12, 2026 implementation date.
What TOEFL Speaking score do foreign pharmacists need?
NABP requires Speaking band 5 for FPGEC certification for tests taken on or after January 21, 2026. That is the old 25 to 26, and it is higher than the nursing and therapy requirement.
Can physicians use TOEFL for ECFMG certification?
No. ECFMG requires the Occupational English Test for Medicine and states there are no exceptions, regardless of whether the applicant is a native English speaker.
How long do I need to prepare for band 4.5?
That depends entirely on where you are starting. The useful step is measuring your current band on the same scale as your requirement before you build a schedule, so you know whether you are closing a gap of half a band or two bands.
Sources
- HRSA, foreign health care worker requirements, current and previous English proficiency minimums
- ETS, TOEFL iBT score scale update and section score concordance tables
- TruMerit, statement on updated HRSA English language proficiency exams and score requirements
- NABP, foreign pharmacy graduate examination committee certification requirements
- ECFMG, certification pathways English language proficiency requirement